Ok, some people do really have weak pelvic floor muscles, but for most people strength is not the issue. Your pelvic floor muscles can have a weak contraction, but that does not mean that your muscles are actually weak. I know this seems like I am talking in hyperbole. It seems like it is all just semantics. What is the difference between weak muscles and weak contraction? Why does it matter anyway?

Because the treatments needed are different!

First, let’s talk about how a muscle contraction occurs. In order to contract your pelvic floor muscles, or any other muscle(s) for that matter, your brain initiates that contraction. Your brain tells your pelvic floor muscles to contract to close the urethra, lift your organs, and close the rectum. Your nerves carry that signal to the muscles and tell the muscles to contract. In a weak muscle, this process goes smoothly, but you have a relatively small number of muscle fibers. The more fibers present, the stronger the muscle, so contracting more times and against more resistance will increase the number of muscle fibers and increase the strength of the muscle in question. More often than not, if someone is experiencing stress incontinence there is a problem somewhere else in the process. More often than not, there is a problem with communication and/or initiation of contraction.

Even if you have strong pelvic floor muscles, you can still have stress incontinence

For most people, one or more of the below reasons will explain your stress incontinence.

1. If your brain is not sure what signal to sendDue to surgery, pregnancy, injury, infection, etc., the brain may be confused about how to communicate with your muscles. You cough, but your brain just forgot to tell your pelvic floor muscles to contract. You assume your muscles are weak because they are unable to stop you from peeing a little bit. In actuality, your brain never told them to contract.

2. If your muscles have an elevated resting tone. Sometimes, because of stress, anxiety, tension, or habit, you may be walking around with your pelvic floor muscles in a partial contraction at all times. Your muscles are not able to respond effectively and efficiently to communication from the brain because they are already contracting. In the case of the pelvic floor muscles, it sometimes seems like this would be fine because the “hose” (or the urethra) would be shut, but it doesn’t quite work that way. Your pelvic floor is not a valve that can be opened and shut. You stay dry as long as the pressure from your pelvic floor muscles against your urethra is more than the pressure of your bladder being squeezed. If you’re muscles are already partially contracted, then they cannot respond. If your muscles cannot respond, then they cannot increase pressure against the urethra as increased pressure is applied to the bladder.

3. If the communication is not fast enoughYour brain may be sending the right message, and your muscles are ready to respond, but the brain sends the message too late, the nerves transmit the message too slowly, and/or the muscles respond with a delay. If your pelvic floor muscles contract after you cough, then you likely won’t stay dry

4. All of the aboveThe majority of my clients experience a combination of the above. That is why neuromuscular reeducation is really the most powerful tool of a physical therapist. First, we helping you break the habit of holding your pelvic floor muscles, then teach your brain what message to send to which muscles, then help you speed that communication and response so that the contraction occurs before the increase in pressure.

I hope this helps you understand how pelvic floor physical therapy can help address your stress incontinence. Let me know what you think and if you have any questions.